CONSENT TO RELEASE CONFIDENTIAL INFORMATION

Name:	KU ID: #

Address:

I, , give my consent to:

Susan Mangold, Student Services Coordinator

Student Services & Campus Life

Kutztown University

Kutztown, PA 19530

to obtain information from/disclose information to my professors:

All professors

Only the following professors: __________________________________

__________________________________

__________________________________

This information may be disclosed only for the following purpose(s):

Notification of hospitalization; inability to attend classes; coordinate academic services.

The information to be disclosed is:

Date of hospitalization; date of return is not yet certain; academic standing in class.

I understand that I have no obligation to disclose any information from my confidential records. I further understand that I may revoke this consent at any time (except to the extent that action has been taken in reliance thereon) by written notification.

All information released will be handled confidentially. Federal regulation prohibits any further disclosure of this information without the specific written consent of the person to whom it pertains or that which is otherwise permitted by such regulations.

I understand that my authorization shall remain in effect for a period of one hundred twenty (120) days from the date of my signature. I permit a copy of this authorization to be used in lieu of the original.

I have had this form read and explained to me, and I understand its contents.

Signature of Client __________________________________	Date __________________

Signature of Witness ________________________________	Date __________________

revised 10/2010